Meeting Report
Istanbul Proves To Be an Ideal Setting for a Memorable Meeting
A report on the joint meeting of the International Psychogeriatric Association and the Turkish Society of Psychogeriatrics, May 1998

Robert Stewart

As the venue for an international academic meeting, it is difficult to think of anywhere quite as appropriate as Istanbul, a city that uniquely spans two continents and which, as the capital of two of the longest lasting empires in history, has been a center of learning and a melting pot of diverse cultural influences for millennia. As shining glass elevators hummed their way up and down the soaring Polat Renaissance Hotel, it was difficult to say that history exactly looked down on us, but history was only a short(ish) coach ride away.

Added relevance for old age psychiatry came, as Barry Reisberg reminded us, from Arataeus of Cappadocia (now Turkey), who provided the earliest surviving suggestion of old age as a cause of dementia -- missing out on a Medline citation by the odd millennium, but surely an emeritus IPA directorship would be in order as compensation?

Perhaps one of the most rewarding aspects of the care of older people is the wealth of experience and detail recounted in the life stories we are told. It was therefore fitting that the first full day of the conference commenced with a biography, that of the French psychiatrist de Clérambault. Known to many of us through his description of erotomania, he was (as eloquently revealed by our past president Raymond Levy) also a complicated man in whom a number of factors appeared to combine to precipitate a depressive psychosis and his subsequent suicide at the age of 62.

Throughout the proceedings a number of themes could be seen emerging and, given the diversity of our backgrounds, it was not surprising that cross-cultural experiences were among the most prominent. An overview of work examining cognitive performance and dementia in different international settings, presented by M. Richards, was complemented by James Lindesay’s account of UK research examining cognitive performance in elderly Gujarati and European-born subjects, raising the possibility that education, rather than ethnicity, accounts for most of the observed differences in performance. Low service uptake by ethnic minority elders had been the initiating factor for the latter study, and research exploring this issue in a memory clinic service in Melbourne, presented by David Ames, demonstrated higher levels of burden and less utilization of services in carers of non-English speaking subjects.

Cross-cultural research on affective disorder moved from the experiences of A. R. Abas in the development of a culturally sensitive depression scale for older Caribbean-born UK residents, to O. Agbayewa’s research in Vancouver, finding a combination of ethnicity, immigration and language spoken to account for approximately 20% of the variance in admission rates for depression in old age. Factors associated with migration of the elderly were reviewed at length by M. Tropper, accompanied by extensive data from a longitudinal study in Israel.

These issues, of course, entered into a number of other presentations as well. A. Phanjoo’s review of the assessment and management of sexual problems in the elderly, for instance, was followed by a lively discussion concerning how these expressed themselves in different cultures. Our host, Engin Eker, presented a large body of recent research conducted with T. Ertan and other colleagues on the prevalence of late life depression in Turkey, stressing the current under-recognition of this problem despite considerable associated morbidity. It was interesting to hear about lower levels of depression in residential care compared to community settings, a reversal of what is generally found in Western Europe.

So where does cross-cultural research go from here? Whilst validation and piloting of diagnostic and screening instruments in different settings obviously requires more work, it was refreshing to hear Vijay Chandra’s plea for a move towards explaining rather than describing differences in disease prevalence (incidence data still lamentably scant), particularly with regard to dementia. Cross-cultural studies provide an important opportunity to study environmental effects, which may not vary sufficiently within a single country’s population to be picked up as risk factors.

If a useful division of disease risk factors into genes and environment exists, then discussions could be said to have weighed more towards the latter. The presentations by Karen Ritchie, Vijay Chandra, and Robin Eastwood on Alzheimer’s disease risk factor research covered gene-environment interactions, as well as updating us on recent research into the role of early life factors such as education. Cerebrovascular disease, an environmental risk factor for dementia but probably with genetic

interactions, was discussed by A.D. Korczyn, leading to a discussion of the role of hypertension as a risk factor for dementia.

Presentations on late-life depression again focused on environmental factors. J. Copeland updated us on EURODEP findings and A.W. Braam presented an interesting analysis from this database and the Amsterdam Longitudinal Aging Study, examining associations between local religious climate and the prevalence of depression in later life. Later in the proceedings, Henry Brodaty expanded this etiologic discussion by examining the complex interrelationship between late-life depression and dementia, suggesting cerebrovascular disease as a potential underlying factor.

While a number of presentations reviewed and presented research into the causes of late-life psychiatric disorders, it was good to see still more on the consequences and on what can be done to ameliorate the suffering of subjects and carers, particularly in the context of dementia. The development and gradually increasing availability to clinicians of anticholinesterase medication unsurprisingly emerged in many of the discussions. The current situation with regard to anti-dementia drugs was reviewed by Koho Miyoshi, but there was a greater emphasis on the difficulties placed on carers and clinicians by behavioral changes associated with dementia. R. Ham and Prof. Newhouse reviewed research to date into BPSD (Behavioral and Psychological Symptoms of Dementia -- just as well we have the mnemonic!) and Sanford I. Finkel outlined recent conclusions and recommendations from an IPA task force on the subject. A. Gögüs reminded us of the problems of polypharmacy in older patients, and the assessment and management of delirium was covered by R. Ham. Barry Reisberg proposed an interesting model for the progression of Alzheimer’s disease as a reversal of early life cognitive development (what you gain last you lose first), a process suggesting that the most thinly myelinated areas of the brain may have a particular vulnerability to dementia pathology.

A healthy number of presentations discussed ways in which carer stress and burden could be reduced, commencing with a workshop chaired by E.E. Benezra. Kazuo Hasegawa described a Japanese day hospital model with the interesting idea of allowing carers to observe relatives’ occupational and recreational therapy programs through a two-way mirror, and P.A. Miller outlined a group therapy program recently piloted in the USA. Alistair Burns presented research examining factors associated with carer distress. He suggested that we could learn from family work in schizophrenia with negative expressed emotion and attributions of intentionality to behavioral problems appearing to correlate well with carer difficulties and raising the potential for targeted interventions.

The ‘carving up’ of disorders into diagnostic categories has always been a thorny issue in psychiatry and it was not surprising that existing criteria came in for some criticism. A categorical system’s clinical utility can be a significant hindrance for objective research and epidemiology may be a field more vulnerable than most in this respect. The disappearance of paraphrenia from diagnostic systems has received considerable criticism in the past from those interested in the late-life development of psychotic illness, and R. Howard’s presentation in this area emphasized the inadequacy of the current situation, particularly with regard to lifetime incidence rates of psychosis and symptom profiles, which raise questions as to whether early-onset and late-onset disorders are usefully considered in the same category. This discussion was paralleled by Michael Davidson’s review of aging and cognitive deterioration in young-onset schizophrenia. It was a shame that these two complementary lectures could not have been linked together in a single symposium.

An interesting presentation by A. Treloar challenged preconceptions about delirium in old age, the problem being that descriptions of acute confusional states are derived from younger age groups and that longitudinal work is lacking which examines assumptions about reversibility and the questionable distinction between acute and chronic cognitive decline. In a similar vein, Edmond Chiu discussed the grey area between late-life depression and dementia, suggesting, with the degree of symptomatic overlap between the two conditions, a common underlying process (possibly affecting fronto-subcortical function) with varying degrees of reversibility.

The symposium on the role of vascular disease in dementia reiterated growing dissatisfaction with the current dichotomy between vascular dementias and Alzheimer’s disease. Defining a condition according to the presence or absence of a possible underlying cause naturally does not help objective analysis as to the role of that cause and, in the case of dementia, does not reflect reported high degrees of mixed pathology. In all these areas, it is to be hoped that increasing recognition of overlapping spectrum disorders, particularly in later life, will facilitate the development of research diagnostic systems with more of an axial than categorical basis.

So what was missed? Obviously there has to be some focus for a three-day event and, in this case, it was clearly epidemiological, with relatively little comment on the rapidly expanding neuroscientific understanding of dementia pathogenesis or of neuro-imaging research, apart from some interesting fMRI findings presented by R. Howard investigating visual hallucinations in Charles Bonnet syndrome and suggesting chronic understimulation of the primary occipital cortex as a basis for this. Presentations on dementia covered Alzheimer’s disease and vascular dementias with little mention of other disorders such as Lewy body disease or fronto-temporal degeneration.

And what hospitality!

It would be impossible to give an accurate account of conference proceedings without some mention of what went on outside the lecture theatre -- and I am reliably informed that (apart from a quick skim-through by speakers to check that their name has been mentioned with all due deference) this is the only part that anyone ever reads. However, aside from the rarefied atmosphere of academia and distinguished presentations of invariable excellence, an enduring memory has to be the (typical) Turkish hospitality shown by Engin Eker, our host, and by the hard working team from Dilan Tur who organized the event. Credit also must go to the interpreters, whose difficult job making sense of fast-spoken, complex presentations was made apparent to English-speaking delegates as images of Hittite gods and Anatolian mandalas emerging from the darkness seamlessly followed Barry Reisberg’s welcome (you had to be there).

A cocktail reception seemed to be the only logical conclusion to this, and those who dared to ask found that supplies of raki (the local hard stuff) were indeed available, but were kept discretely out of sight and accompanied by a health warning concerning likely symptoms the following morning. The unforgettable surroundings of the Ciragan palace on the shores of the Bosphorus were the setting for the Gala Dinner, where it was good to see some of our elder statesmen showing that age is no barrier to the rigors of the dance floor (must be the Merseyside air). As the sun set (or soft rain fell) over the sea of Marmara outside our venue, it was difficult to think of a more memorable setting for an excellent conference.

About the Author

Robert Stewart is based at the Old Age Psychiatry Section, Institute of Psychiatry, DeCrespigny Park, Denmark Hill, London SE5 8AF, UK, Fax +44 171 701 0167, E-mail: spjurjs@mail.iop.bpmf.ac.uk

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Reprinted from IPA Bulletin, Volume 15, Number 3